Emory Healthcare

Part of the problem of antibiotic resistanceÂ involves physiciansâ€™ habits. Doctors are used to prescribing antibiotics in certain situations, even when they may be inappropriate or when alternatives may be best. However, they may be susceptible to â€œnudgesâ€, even if health care organization policies donâ€™t formally restrict their choices. Former White House regulatory policy guru Cass Sunstein has written several books on this concept.

In March 2015, MD/PhD student Kira Newman and colleagues published a studyÂ in Journal of General Internal Medicine that has some bearing on this idea, althoughÂ it doesnâ€™t address antibiotic resistance directly:

The authors describe a shift involving the Emory University hospital electronic health record and order entry system. When a patient has systemic or urinary tract bacterial infection, the system shows a table of antibiotic sensitivity data alongside blood or urine culture results.

Beginning in May 2010, cost category data for antibiotics were added. Explicit numbers were not included â€“ too complicated. Instead, the information was coded in terms of $ to $$$$. For the year after the change, the authors report a 31 percent reduction in average cost per unit of antibiotics prescribed. Read more

John Puskas, chief of cardiac surgery at Emory University Hospital Midtown, recently had an editorial in the journal Circulation on the topic of coronary bypass surgery.

John Puskas, MD

Specifically, he says that many cardiac surgeons are reluctant to employ bilateral internal thoracic artery grafts (as opposed to a single graft), even though there is a long-term benefit, because of perceived risk of infection and suboptimal financial incentives.

Puskas’ key message paragraph was so clear that it demands reposting here:

Why are American surgeons doing so few BITA [bilateral internal thoracic artery] grafts? Fundamentally, U.S. surgeons are responding to their practice environment, especially to a fear of deep sternal wound infection in an increasingly obese, diabetic population of patients. The surgeon pays a large and immediate political price for a deep sternal wound infection and receives relatively little credit for the extra years that BITA grafting adds to a patient’s life in the future. There is also a relative Ray Ban outlet financial disincentive to perform BITA grafting: incremental payment for the second internal thoracic artery graft is small considering the extra time required in the operating room. Moreover, the Centers for Medicare and Medicaid Services no longer reimburse for extra care necessary for treatment of mediastinitis [internal chest inflammation/infection] after cardiac surgery, because this is now deemed a never event. Thus, surgeons, who are increasingly employed by hospitals and hospital systems, are under intense pressure to perform CABG surgery that is safe and cost-effective according to short-term metrics.

Puskas and his colleagues have published an analysis of bilateral vs single grafting at Emory, as well as a proposed metric for when single grafting should be used in the context of patients with diabetes:

Our present practice is generally to use BITA grafting in patients who are <75 years, have suitable coronary artery targets, are not morbidly obese, and whose glycosylated hemoglobin level is <7.0% to 7.5%.

As Dr. Sarah Vinson rotated through her first year of clinical work as a Child Psychiatry Fellow in the Department of Psychiatry and Behavioral Sciences at Emory, she quickly became aware that there are some significant roadblocks in getting people in the African-American community engaged in treatment for mental health problems.

Sarah Vinson, MD, Department of Psychiatry and Behavioral Sciences

â€œMisinformation, an absence of trust in the system, racism and financial circumstances are some of the forces that can create barriers in making appropriate decisions about seeking treatment,â€ says Vinson.

In order to take a step toward resolving the problem, Vinson created an online mental health outreach program targeting the Black community. The website serves as an anonymous resource for patients and their families, or anyone who is interested in finding out more about mental illness.

This user-friendly online program provides educational materials, offers links to professional organizations, lists mental health professionals and provides descriptions of different types of mental illnesses as they relate specifically to African-Americans. The website also includes an interactive forum where people can share experiences.

â€œPeople may be fearful of being misjudged by their churches and families, so they donâ€™t discuss their problems,â€ she explains. â€œHowever, it is the support of family and friends that is largely responsible for a successful course of treatment; particularly when it comes to children and adolescents, or people with severe mental illness. Regrettably, when people access care without reinforcement from their loved ones, they often drop out before they are better.

â€œUntreated, mental illness can cause strained relationships, social dysfunction, and numerous other problems that can end up in divorce, unemployment, and suicide.â€

Dr. Vinson is the recipient of an American Psychiatric Association/Substance Abuse and Mental Health Services Administration Fellowship, which provides funds for programming related to minority mental health.

Once esophageal tumors establish themselves, a patientâ€™s prognosis is grim and morbidity vast. But when lesions are caught early and removed, especially in the premalignant stage, the odds of survival markedly improve.

When a case calls for it, Emory gastroenterologist Field F. Willingham, MD, MPH, uses a hybrid approach to ousting superficial esophageal lesions. Superficial esophageal lesions are commonly caused by acid reflux disease, or GERD. GERD occurs when stomach acid flows into the esophagus and can lead to a condition known as Barrettâ€™s esophagus, where the cells in the lower esophagus become damaged. This in turn can lead to dysplasia, or pre-cancerous cells.

But for superficial cancers, it is now possible to remove a portion of the lining layer of the GI tract, containing the tumor, with an endoscope.Â This can help carefully selected patients avoid a major surgery. The technique, known as an EMR, allows the removal of superficial esophageal tumors and pre-cancer with an endoscope, a slender tube-like instrument.

Detecting and removing esophageal tumors early is essential for a favorable outcome. Once tumors firmly establish themselves in esophageal tissue, the prognosis is grim and morbidity vast. In the past, a diagnosis of an esophageal tumor meant the removal of the esophagus and often the stomach. But now EMR can be used in tandem with radio frequency ablation.

In surgical situations in which radio frequency ablation is not feasible, Willingham and his colleagues are beginning to use an alternate technique, known as cryotherpay, in tandem with EMR. Cryotherapy involves freezing superficial cells to rid the esophagus of suspect cells.

â€œSo, if the end of the esophagus is twisted, or if we canâ€™t touch it with this balloon device, then we can use cryotherapy,â€ says Willingham. â€œWeâ€™re trying to kill the lining layer with the tumor cells without killing the deeper layer.â€

Willingham and his colleagues are seeing evidence that using these very three very different, technologies in tandem or alone will provide patients with a better way to rid them of esophageal lesions while preserving their quality of life.

Smokingâ€™s link to lung cancer has been well-known for decades, but we are still learning about its cancer-causing effects on other organs.

An article in the Journal of the American Medical Association (JAMA) provides solid epidemiological evidence that smokingâ€™s link to bladder cancer is even higher than previously believed. And, the elevated risk factor appears to be the same for men and women.

Viraj Master, MD, PhD

â€œThis is something I see in my practice every day,â€ says Viraj Master, associate professor of urology, Emory School of Medicine and director of urology clinical research at the Winship Cancer Institute of Emory University. â€œThe dangers of smoking are pervasive. Patients are often surprised to hear of the link between smoking and bladder cancer, but itâ€™s there, and itâ€™s a very real risk.â€

The bladder may not be the first organ you think about when you think about the harmful effects of cigarette smoking. After all, when a person inhales cigarette smoke, the mouth, throat and lungs are the primary destination. But, a lethal change in the composition of cigarettes makes the bladder a target for cancer.

Written by researchers at the National Cancer Institute, the study explains that while there is less tar and nicotine in cigarettes now that in years passed, there also has been â€œan apparent increase in the concentration of specific carcinogens,â€ including a known bladder cancer carcinogen and tobacco-specific nitrosamines. The study authors also note that epidemiological studies have observed higher relative risk rates associated with cigarette smoking for lung cancer.

â€œThe take-home message, of course, is the same as it long has been â€“ donâ€™t start smoking, and if you do smoke, stop,â€ says Master. “We need to do everything in our power to both stop people from starting to smoke and to help those already addicted to stop.â€

Thatâ€™s the motto 36-year-old Jennifer Giliberto now lives by after recently welcoming a third child into the world. Late night feedings, diaper changes, mounds of dirty laundry and caring for two older boys (ages six and eight) would certainly be a challenge for most moms. But this mom is different.

Four years ago, Giliberto was diagnosed with a brain tumor â€“ a slow growing Grade II astrocytoma located in her posterior right temporal lobe. The shocking diagnosis left Giliberto and her family with many choices and decisions to make.

Gilibertoâ€™s inspiring story was profiled on CNN on Aug. 16, 2011 in a special â€œHuman Factorâ€ segment, which takes a look at people accomplishing something significant after overcoming the odds.

The Long Road Ahead

After her second child was born in 2005, Giliberto began noticing a pattern of problems with her fine motor skills. Neurological testing revealed little, but an MRI (magnetic resonance imaging) revealed a lesion and possible tumor in the brain. Follow-up MRIs over the next year showed no new growth, but in June 2007, a definite brain tumor was detected by MRI.

Hadjipanayis, an assistant professor in Emoryâ€™s Department of Neurosurgery, would soon become Gilibertoâ€™s physician. He confirmed her diagnosis and recommended surgical removal of the tumor.

Costas Hadjipanayis, MD, PhD and patient Jennifer Giliberto

On August 18, 2008, at Emory University Hospital Midtown, Hadjipanayis removed Gilibertoâ€™s brain tumor. â€œJennifer underwent a craniotomy and had a gross total resection of the tumor, with no complications,â€ explains Hadjipanayis, who is chief of neurosurgery at the hospital. â€œShe spent one night in the neurosurgical ICU and her recovery afterwards went well.â€

Then he encouraged her to embrace life and live it to the fullest. Giliberto has taken her doctorâ€™s orders to heart, and lives life with a new purpose than before.

Giving Back

To support and encourage other brain tumor patients, Giliberto serves as a patient and family advisor at Emory University Hospital Midtown. She visits with hospitalized patients and their families who are in similar situations as the young mother of three.

â€œThis has been a very fulfilling experience and an outlet to give back,â€ says Giliberto. â€œBeing a patient is lonely, even when you know you have support. Working to assist other patients and families and improve a system goes a long way to ease that lonely journey of the patient experience.â€

Patient and family advisors also work to improve hospital processes and procedures from a patient perspective.

She also serves as vice president of the Southeastern Brain Tumor Foundation, continuing the mission to raise funds for research. The SBTF consistently funds innovative brain tumor research at Emoryâ€™s Winship Cancer Institute.

And she is a devoted wife and mother.

Moving Forward

Last year, when Giliberto and her husband decided they would like to expand their family of four, she consulted with Hadjipanayis. He, once again, encouraged her to live life and move forward. They did, and their youngest child was born in July 2011.

While Giliberto has remained stable since her surgery in 2008, she continues to have MRIâ€™s every six to nine months to check for any tumor recurrence. Astrocytomas, even once removed, can recur and can also become cancerous.

But for now, itâ€™s on with life as she knows it â€“ stable, moving ahead and enjoying every day with a new sense of hope.

And as for the small stuff â€“ Gilibertoâ€™s learned thereâ€™s just no reason to sweat it at all.

Seems pretty obvious â€“ if a sunscreen with an SPF of 30 is good, then an SPF of 100 should be at least three times as good.

Unfortunately, that is not the case.Â There are other important details to consider when you are purchasing a sunscreen.

â€œPeople have become much more educated about the importance of using sunscreen, and manufacturers have responded with an abundance of products,â€ says Carl Washington, MD, associate professor of Dermatology at Emory University School of Medicine. â€œUnfortunately, the labeling can be confusing and many of the current sunscreens only contain the ingredients necessary to offer protection against sunburn, but not skin cancer or aging.â€

Recently, the Food and Drug Administration created new regulations to establish standards for sunscreen manufacturers to follow before they label their products.

Under the new regulations, which will go into effect in 2012, sunscreen products that protect against alltypes of sun-induced skin damage will be labeled â€œbroad spectrumâ€ and â€œSPF 15â€ or higher on the container. Only products that have been tested to ensure they protect against both UVA (ultraviolet radiation A) and UVB (ultraviolet radiation B) radiation will be allowed to use this labeling.Â Broad-spectrum sunscreens of SPF 15 and higher can also be labeled as protective against skin cancer and premature aging. The maximum SPF value is set at 50-plus because the FDA says anything higher doesnâ€™t provide a significant amount of additional protection.

Manufacturers will have to include warning labels on products that are not broad spectrum. Products that claim to be water resistant must indicate how long the consumer should expect to be protected in the water, and using such language as â€œwaterproofâ€ or â€œsweat proofâ€ will not be allowed.

â€œSkin cancer is the most common form of cancer in the United States, and the number of people affected keeps rising. Simply getting into the habit of using a sunscreen every day – with the appropriate levels of protection – can make a significant difference in preventing many skin cancers, as well as premature aging,â€ says Washington.

â€œThese new regulations will help consumers understand the difference in degrees of sun protection, and choose carefully.â€

Washington also suggests staying out of direct sunlight between 10 am and 2 pm, seeking shade when you are outdoors, remembering to reapply sunscreen every two hours and wearing protective clothing.

Can it really be possible to transform a person’s own cells into a weapon against various forms of disease? And what if those very cells could be retrained to attack cancer cells or to prevent autoimmune diseases?

Answers to these questions and many more are about to soon be realized, as Emory University Hospital will serve as the launch site for the very appropriately-named EPIC (Emory Personalized Immunotherapy Center).

The new Center, which is the creation of Dr. Jacques Galipeau, MD, professor of hematology and medical oncology & pediatrics of Emory University, will soon be operational after final touches have been put on construction of the lab. This cell processing facility will foster development of novel personalized cellular therapies for Emory patients facing catastrophic ailments and unmet medical needs.

According to Galipeau, the premise of EPIC and its overlying mission will focus on cellular and biological therapies that use a patientâ€™s own cells as a weapon to seek and destroy cells that actually make a person sick. In partnership with the Winship Cancer Institute of Emory University, Childrenâ€™s Healthcare of Atlanta, Aflac Cancer & Blood Disorders Center and the Emory School of Medicine, EPIC seeks to improve the health of children and adults afflicted with cancer and immune disease.

â€œFirst and foremost, we seek to bring a level of care and discovery that is first in Georgia, first in human and first in child. Blood and marrow derived cells have been used for more than a quarter century to treat life threatening hematological conditions and are now established therapies worldwide. More recently, the use of specific adult somatic cells from marrow, blood and other tissues are being studied in cellular medicine of a wide array of ailments including heart, lung, neurological and immune diseases,â€ says Galipeau. â€œThe use of blood borne immune cells can also be exploited for treatment of cancer, autoimmune disease, organ transplantation and chronic viral illnesses such as HIV.â€

Galipeau said that once operational, EPIC willÂ begin by working with Crohnâ€™s disease in pediatric and adult patients, an inflammatory bowel disease. Symptoms of Crohnâ€™s disease include severe abdominal pain, diarrhea, fever, weight loss, and the inability for a child to properly grow. Resulting bouts of inflammation may also affect the entire digestive tract, including the mouth, esophagus and stomach.Â In some cases, a radical surgery involving the removal of part of the lower intestinal tract is required.

â€œThere is no current answer for what specifically causes Crohnâ€™s disease, nor is there a cure. But we hope that through our research and efforts, we will be able to first target the inflammatory mechanisms in these patients through immunotherapy, and in turn reduce the amount of flare-ups and limitÂ the damage that occurs from this disease,â€ says Galipeau.

Galipeau says the EPIC program could represent a powerful cornerstone to the launch and the development of an entirely new, Emory-based initiative which bundles the strengths of the School of Medicine, Emory University Hospital, Children’s Healthcare of Atlanta, and many Woodruff Health Sciences Center centers of excellence,â€ says Galipeau.

â€œMy ultimate goal is to elevate the biomedical scientific and scholarly enterprise to aÂ higher level – making a difference in the lives of people. The EPIC program and multi-levels of support could be a fundamental underpinning to our success.â€

Tracey-Ann Read, PhD, assistant professor in the Department of Neurosurgery, Emory University School of Medicine and director of the Pediatric Neuro-Oncology Laboratory at Emory was awarded a $75,000 grant for her work. She is studying the cell of origin that is responsible for the highly malignant pediatric brain tumor known as an Atypical Teratoid Rhabdoid Tumor (AT/RT). She is also developing a mouse model to study this very lethal brain cancer that occurs in early childhood.

Robert Craig Castellino, MD, assistant professor of pediatrics at Emory and pediatric hematologist/oncologist at Childrenâ€™s Healthcare of Atlanta at Egleston received $50,000 to support his research efforts. He is studying how the childhood brain cancer, known as medulloblastoma, can metastasize from the brain to other sites in the body, specifically the spine. Medulloblastoma is the most common pediatric malignant brain tumor.

SBTF board members and researchers who were awarded grants pose following the April ceremony.

Read and Castellino received the awards at the SBTFâ€™s Grant Awards Ceremony in April at Emory University Hospital Midtown. Two other researchers from Duke University were also presented with grant money for their contributions in brain tumor research in adults.

Emory neurosurgeon Costas Hadjipanayis, MD, PhD, is the president of the Southeastern Brain Tumor Foundation. He says research, from young investigators such as these, is crucial in the race to find a cure for brain tumors. As federal research funding becomes even more difficult to obtain with cuts in funding, private foundation grants, such as from the SBTF, can permit researchers to start important research projects that can provide preliminary data for bigger grant proposals.

The SBTF awards $200,000-300,000 each year to major medical centers throughout the Southeast in support of cutting-edge brain and spinal tumor research.

This weekâ€™s issue of the Atlanta Business Chronicle spotlights the winners of its annual Healthcare Heroes Awards, recognizing the contributions of top medical professionals in the Atlanta health care community. Emory was well represented again this year among the impressive list of winners and finalists. Winners included:

Linda Cendales, MD, assistant professor of Surgery at Emory University School of Medicine, nominated in the Healthcare Innovations category for successfully performing the stateâ€™s â€“ and one of the nationâ€™s â€“ first hand transplants on a college student from Orlando, Fla. (see Emory article)

Katherine L. Heilpern, MD, professor and chair of the department of emergency medicine, nominated in the Physician category for her contributions to emergency and trauma care and for her leadership among 5 hospitals in Metro Atlanta which receive 250,000 patient visits per year.

Curtis Lewis, MD, assistant professor of radiology, Emory University School of Medicine, nominated in the Physician category for his management and training of physicians and residents in his role as chief of staff and senior vice president of medical affairs at Grady.